Provider Demographics
NPI:1922594142
Name:KEENER, KELI NICOLE (MSED, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KELI
Middle Name:NICOLE
Last Name:KEENER
Suffix:
Gender:F
Credentials:MSED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4063 FRANK SCOTT PKWY W
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-6802
Mailing Address - Country:US
Mailing Address - Phone:618-222-7635
Mailing Address - Fax:
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5368
Practice Address - Country:US
Practice Address - Phone:618-257-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0020572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty